Abstract
This study aims to analyse the consequences of a lack of documentation in a community-based
rehabilitation (CBR) unit for children with disabilities. 278 hours of observation and two structured
interviews were conducted. Observation notes were depicted in a fishbone chart and interview findings
were coded manually in a series of open, axial, and selective coding. The findings, field notes, and selfreflective notes were triangulated and link thematically. The findings revealed that the unit does not yet
have a standardised documentation guidelines and forms. Failures to address children‘s needs and
progress, inability to modify the intervention and audit the quality of care based on evidence and lack of
confidence in the therapists‘ professionalism are the common problems experienced by the therapists due
to lack of record-keeping. These are evaluated as contributing factors to risks of patients safety and poor
quality of care. While the needs of CBR units are greatly increased for people with disabilities, CBR
organisations and the Indonesia physiotherapy association need to cooperate in order to develop a clear
clinical pathway and standardised documentation for a CBR context.
rehabilitation (CBR) unit for children with disabilities. 278 hours of observation and two structured
interviews were conducted. Observation notes were depicted in a fishbone chart and interview findings
were coded manually in a series of open, axial, and selective coding. The findings, field notes, and selfreflective notes were triangulated and link thematically. The findings revealed that the unit does not yet
have a standardised documentation guidelines and forms. Failures to address children‘s needs and
progress, inability to modify the intervention and audit the quality of care based on evidence and lack of
confidence in the therapists‘ professionalism are the common problems experienced by the therapists due
to lack of record-keeping. These are evaluated as contributing factors to risks of patients safety and poor
quality of care. While the needs of CBR units are greatly increased for people with disabilities, CBR
organisations and the Indonesia physiotherapy association need to cooperate in order to develop a clear
clinical pathway and standardised documentation for a CBR context.
| Original language | English |
|---|---|
| Journal | Jurnal Sosial Humaniora Terapan |
| Volume | 2 |
| Issue number | 2 |
| Publication status | Published - 2020 |